GW1--04781_Well Construction - GW1_20230724

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WELL CONSTRUCTION RECO _ (GW-1) For Internal Use Only: . .
• 1.W C ,;auto t i ti 1 ,
1. • '14.WATER ZONES
Well ContractorName FROM TO DESCRIPTION
3 53S • clod ft' CroUft
• ft.
C Well Contractor Certification ber IS.OUTER CASING(for multi cased welts)OR LINER(if ap linable)
I I FROM TO DIAMETER THICKNESS MATERIAL
1-A. V 1 I Y/</11,. • ft ft. in
CompaxrName /�
A174 16.INNER CASING OR TUBING(geothermal closed-loop) •
2.Well Construction Permit#: (, r1 -1-FROM TO DIAMETER THICKNESS MATERIAL
P�
List all applicable well construction permits e.UIG County.State,Variance.etc.) 1 I tit 70 R �yilL / ,!r•t,. p�,
3.Well Use(check well use): •
.O
• W ter Supply Well: • d7.SCREEN •
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
• Agricultural •OMunicipal/Public ft _ ft • ... fa
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft . ft in.'
❑lndustriallCommercial ❑Residential'Water Supply(shared) 18.GROUT
❑Irrigatiog ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT &AMOUNT
Non-Water Supply Well: 0 ` ft 23 ft , 'I/� H /l f�,l ✓'
• ❑Monitoring ❑Recovery ft ft pa r-f ` d •P T,-"1• Injection Well:
ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery. . ❑Salinity Barrier • ' ' FROM TO MATERIAL EMPIACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft • R. •
[Experimental Technology ❑Subsidence Control ft ft. "
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• ❑Geothemtal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO • DESCRIPTION(color,hardness,soil/rock type,grain she,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft it '
4 4.Date Well(s)Completed: 7-1.--2-..3 Well ID# ft ft •
Sa.WellLocation: ft ft. R E ,i' � it r ,
Rai C ft. ft.
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4 5s��v e ns -��.� rn r�>,r,� JUL• Facility/Own r Name Facility ID#(if applicable) ft ft. Jd [! [ L
�
e � k�I --Mt..,I h t cJhr rid . •
'"tt fG ifnior7i1a.K.Irt Prn:7?00if:)I ln.,
•Physical Address,City,and Zip ft. ft D4�. ,: (3‹,;
/;tr�..E I(
1 i h ,21.REMARKS/
Coil. (! Parcel Identification No.(PIN) •
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wesuffi
cient)field,one lat/long is 22.Certification:
. (//D) 12' TX- N 6 i ct o 1 q I 1
W ' /t‘.''L?j
AP
6.Is(are)the well(s): ❑Permanent or ❑Temporary / b2Ul Signature Certis '•Well Contractor Date
By signing this form,I hereby cert�that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or jl1io 1SANCAC 02C:0100 or7SJI NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction Information and drplain the nature of the of this record has been provided to the well owner.
'repair under#2I remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
• construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
• " drilled:
// !� 24.SUBMITTAL INSTRUCTIONS '
9.Total well depth below land surface: (D di"
For multiple wells list all depths iifdierent(example-3Qa 200'and 2 r@ (ft)( ) Submit this GW 1 within 30 days of well completion per the following:
10.Static water level below top of casing. �p (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing.use" /� Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 •
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11.Borehole diameter. ,(in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
%1 - ^ Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:' 2►ti 1 /�n, 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,eta)c.)
county environmental health department of the county where installed
• FOR WATER SUPPLY WELLS ONLY: • 24d.For Water Wells producing over 100,000 GPD:Co to D
13a.Yield(gpm) J Method of test: ,(� . Permit Program,1611 MSC,!Raleigb,NC 27699-1611 py VVR'CA A
13b.Disinfection type: IT I+ Amount: ` Z N